Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update for

Medical Guidelines	Reason for Update
Breast Duct Endoscopy	Added policy guidelines, key words, and reference sources. No change in criteria.
Breast Ductal Lavage	Added policy guidelines, key word and reference sources. No changes to criteria.
Continuous Local Delivery of Anesthesia to Operative Site	Reference sources added. No changes to criteria.
Cough Stimulating Device	Notification of new policy titled "Cough Stimulating Device." The use of a cough stimulating device (mechanical insufflation-exsufflation) may be considered medically necessary in members with neuromuscular disease or spinal cord injury and impaired ability to cough and who require ventilatory assistance. Notification date 7/24/06. Effective date 10/2/06.
Dental Inpatient and Outpatient Services	Evidence Based Guideline changed to Medical Policy.
Endoluminal Radiofrequency or Laser Ablation for Venous Insufficiency	Notification of new policy. This policy is NOT effective until 10/2/06. Prior to10/2/06 refer to policy number SUR6817, Venous Insufficiency. The Venous Insufficiency policy will be archived on 10/2/06. Notification given 7/24/06. Effective date 10/2/06.
Functional Capacity Assessment and Work Hardening	Specialty Matched Consultant Advisory Panel review 8/21/06. No changes to policy coverage criteria.
Growth Hormone	Added "Omnitrope" to "Description" and "Key Words" section. Removed lab values from B.1 and B.2. under the "Policy Guidelines" section. It now states "B.1. For children and adults, Growth Hormone deficiency is defined as an abnormal response to one provocative stimulation tests (e.g., L-dopa, clonidine, glucagon, propranolol, arginine, or insulin challenge test). B.2.Chronic renal insufficiency is defined as elevated serum creatinine concentrations or a lower than normal creatinine clearance/glomerular filtration rate, less than 75 ml/ min per 1.73 m2.
Infusion Therapy in the Home	Added key word and reference source. HCPCS deleted codes G0345, G0346, G0347, G0348, G0349, G0350, G0351, G0353, G0354, G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363 removed from "Billing/Coding" section. No changes to criteria.
Liver Transplant	Under "When Covered", A.1.b. "Viral hepatitis (all blood types)", now reads "Viral induced-hepatitis (all viral types)". Under "When Not Covered" 2. Contraindications, removed a. HIV- positive patient. Under "Policy Guidelines" C. Disease Specific Indications, 6.b. added "or HBeAg neg, HBV DNA pos,"; added 9. "HIV positivity: CD4 count >100cells/mm3; HIV-1 RNA undetectable; On stable anti-retroviral therapy >3 months; No other complications from AIDS (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioses mycosis, resistant fungal infections, Kaposi's sarcoma, or other neoplasm); Meets all other criteria for transplantation. It is likely that each individual transplant center will have explicit patient selection criteria for HIV positive patients." Reference sources added.
Observation Room Services	Added statement to Description: Observation care provides a method of evaluation and treatment as an alternative to inpatient hospitalization. Moved the statement regarding "Outpatient services being used for the convenience of the hospital, physicians, patients or patients' families" to the Not Covered section. Added the following statement to the Covered section: the medical necessity for inpatient treatment is unclear because the delayed or slow progression of a patient's signs and symptoms makes quick diagnosis difficult, and the patient's monitoring and treatment does not meet hospital inpatient level of care. Added a list of services that are not considered appropriate for observation room services (this list is not all inclusive). Item #4 deleted from Policy Guidelines. Documentation requirements added to Billing/Coding section. References updated. All references to Milliman Care Guidelines removed from policy.
Pressure Reducing Support Services	Notification of new policy titled "Pressure Reducing Support Surfaces." BCBSNC will provide coverage for Pressure Reducing Support Surfaces when they are determined to be medically necessary because the medical criteria and guidelines outlines in the policy are met. Notification date 7/24/06. Speciality Matched Consultant Advisory Panel review 8/21/06. Effective date 10/2/06.
Reconstructive Eyelid Surgery and Brow Lift	Removed CPT code 15824 from Billing/Coding section. Code is not applicable to this policy.
Rehabilitative Therapies	In the section When Rehabilitative Therapies are Covered, added statement regarding medical necessity of admission and continued stay in acute inpatient rehabilitation facilities that reads: functional goals must be described, the patient is expected to achieve these goals with inpatient rehabilitation and care that cannot be delivered in a less intensive care setting and the patient must require continuous rehabilitation nursing services and close physiatrist supervision and multi-disciplinary rehabilitative services. Typically patients may be treated in a less intensive care setting when: their medical co-morbidities are stable, they require the services of less than two skilled disciplines, they do not require or cannot participate in three hours of active therapy per day, they require minimal assistance or less for mobility, transfers, and gait. Patients may transition to a less intensive care setting (outpatient or home therapy services) when they are mobile, ambulatory for household distances, and capable of performing activities of daily living. The need for some minimum or contract guard assistance is not, in and of itself, a reason for continued inpatient confinement. Also added the following statement: Speech therapy for dysphagia may be covered for actual and identifiable problems resulting from a specific disease or injury (such as a CVA, neuromuscular disease, etc.) and must be conducted pursuant to an evaluation by a qualified therapist and a specific treatment plan that incorporates techniques that have been shown to be scientifically valid. If the recommendation for therapy is based on the findings of a radiographic study (such as a modified barium swallow), the findings must be verified by a radiologist's report. The treatment plan must address the specific problem to be addressed, the specific treatment to be administered, the specific functional goals of the therapy and the reasonable time estimate for achievement of these goals. Statement added to section A of When Rehabilitative Therapies are Not Covered that reads: Low level laser therapy (cold laser therapy) is considered investigational for all indications, including, but not limited to: pain relief, arthritis, carpal tunnel syndrome, Raynaud's phenomenon, fibromyalgia, other musculoskeletal disorders, chronic non-healing wounds, and neurological dysfunctions. Added item 5 regarding investigational treatment of dysphagia: Deep Pharyngeal Neuromuscular Therapy, Vita-Stim and similar non-specific electrical stimulation methods and any therapy involving digital stimulation of the mouth, tongue or pharynx in patients not having a specifically diagnosed neuromuscular disorder specifically and adversely affecting swallowing. Added the following statement to the Policy Guidelines section: Requests for more than one hour of treatment per day will be reviewed on an individual consideration basis. CPT codes updated. Specialty Matched Consultant Advisory Panel review 8/21/06.
Rhinoplasty	Description section revised. When covered section reformatted and added the following to #2. "destructive inflammatory diseases (e.g.,Wegener's granulomatosis, pleomorphic granulomatosis)". Removed "or disease" from When not Covered section - "For change in the external appearance of the nose in the absence of recent (i.e. within the previous 18 months) trauma or injury, or disease." Medical term definition added.
Sclerotherapy as a Treatment of Varicose Veins	Notification of new policy. This policy is NOT effective until 10/2/06. Prior to10/2/06 refer to policy number SUR6817, Venous Insufficiency. The Venous Insufficiency policy will be archived on 10/2/06. Notification given 7/24/06. Effective date 10/2/06.
Septoplasty	Under When Covered section: C.1. and C.2. - removed reference to greater than 50% obstruction; C.2.a. reworded - "There is evidence of clinically significant nasal airway obstruction or difficult nasal breathing (i.e., heavy snoring, mouth breathing, sleep apnea, interference with daily activities due to loss of sleep and accompanying fatigue, headache, poor concentration)"; added C.6.- "Patient has obstructive sleep apnea with a documented respiratory disturbance index (RDI) greater than 5, and septoplasty is being performed to enhance CPAP or BiPAP effectiveness with clinically significant nasal obstruction being documented as the cause of intolerance to CPAP." First entry under "Scientific Background and Reference Sources" revised to indicate correct manual title. Reference sources added.
Spinal Surgery Using Interspinous Distraction Technology	New policy. Spinal surgery using interspinous distraction technology is considered investigational. Notification given 7/24/06. Effective date 10/2/06.
Varicose Vein Excision and Ligation	Notification of new policy. This policy is NOT effective until 10/2/06. Prior to10/2/06 refer to policy number SUR6817, Venous Insufficiency. The Venous Insufficiency policy will be archived on 10/2/06. CPT codes 37720 and 37730 removed from Billing/Coding section (codes deleted in 2005) and added CPT codes 37718, 37722 and 37760. Notification given 7/24/06. Effective date 10/2/06.
Wound Therapy, Noncontact Radiant Heat Bandage	Added policy guidelines and reference sources. Specialty Matched Consultant Advisory Panel review. No changes to criteria recommended.
Xolair (Omalizumab)	Specialty Matched Consultant Advisory Panel review 7/2006. Reference sources added. No changes to criteria.
Evidence Based Guidelines	Reason for Update
Cardiac Rehabilitation	Medical Policy changed to Evidence Based Guideline.
External Cephalic Version	Medical Policy changed to Evidence Based Guideline.
Hysteroscopic Tubal Occlusion for Permanent Sterilization	Medical Policy changed to Evidence Based Guideline.
Implantable Infusion Pumps	Medical Policy changed to Evidence Based Guideline.
Infrared Coagulation	Medical Policy changed to Evidence Based Guideline.
Intraoperative Transesophageal Echocardiography	Medical Policy changed to Evidence Based Guideline.
Intravitreal Drug Delivery System forGanciclovir	Medical Policy changed to Evidence Based Guideline.
Lithotripsy, Extracorporeal, for Gallstones	Medical Policy changed to Evidence Based Guideline.
Patient Controlled Analgesics	Medical Policy changed to Evidence Based Guideline.
Secondary Physician Attendance at Delivery	Medical Policy changed to Evidence Based Guideline.
Sentinel Node Biopsy	Medical Policy changed to Evidence Based Guideline.
Transcoronary Ablation of Septal Hypertrophy (TASH)	Medical Policy changed to Evidence Based Guideline.
Transcranial Doppler Ultrasound	Medical Policy changed to Evidence Based Guideline.